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Nwosu C, Khan H, Masese R, Nocek JM, Gollan S, Varughese T, Bourne S, Clesca C, Jacobs SR, Baumann A, Klesges LM, Shah N, Hankins JS, Smeltzer MP. Recruitment Strategies in the Integration of Mobile Health Into Sickle Cell Disease Care to Increase Hydroxyurea Utilization Study (meSH): Multicenter Survey Study. JMIR Form Res 2024; 8:e48767. [PMID: 38625729 PMCID: PMC11061784 DOI: 10.2196/48767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Hydroxyurea is an evidence-based disease-modifying therapy for sickle cell disease (SCD) but is underutilized. The Integration of Mobile Health into Sickle Cell Disease Care to Increase Hydroxyurea Utilization (meSH) multicenter study leveraged mHealth to deliver targeted interventions to patients and providers. SCD studies often underenroll; and recruitment strategies in the SCD population are not widely studied. Unanticipated events can negatively impact enrollment, making it important to study strategies that ensure adequate study accrual. OBJECTIVE The goal of this study was to evaluate enrollment barriers and the impact of modified recruitment strategies among patients and providers in the meSH study in response to a global emergency. METHODS Recruitment was anticipated to last 2 months for providers and 6 months for patients. The recruitment strategies used with patients and providers, new recruitment strategies, and recruitment rates were captured and compared. To document recruitment adaptations and their reasons, study staff responsible for recruitment completed an open-ended 9-item questionnaire eliciting challenges to recruitment and strategies used. Themes were extrapolated using thematic content analysis. RESULTS Total enrollment across the 7 sites included 89 providers and 293 patients. The study acceptance rate was 85.5% (382/447) for both patients and providers. The reasons patients declined participation were most frequently a lack of time and interest in research, while providers mostly declined because of self-perceived high levels of SCD expertise, believing they did not need the intervention. Initially, recruitment involved an in-person invitation to participate during clinic visits (patients), staff meetings (providers), or within the office (providers). We identified several important recruitment challenges, including (1) lack of interest in research, (2) lack of human resources, (3) unavailable physical space for recruitment activities, and (4) lack of documentation to verify eligibility. Adaptive strategies were crucial to alleviate enrollment disruptions due to the COVID-19 pandemic. These included remote approaching and consenting (eg, telehealth, email, and telephone) for patients and providers. Additionally, for patients, recruitment was enriched by simplification of enrollment procedures (eg, directly approaching patients without a referral from the provider) and a multitouch method (ie, warm introductions with flyers, texts, and patient portal messages). We found that patient recruitment rates were similar between in-person and adapted (virtual with multitouch) approaches (167/200, 83.5% and 126/143, 88.1%, respectively; P=.23). However, for providers, recruitment was significantly higher for in-person vs remote recruitment (48/50, 96% and 41/54, 76%, respectively, P<.001). CONCLUSIONS We found that timely adaptation in recruitment strategies secured high recruitment rates using an assortment of enriched remote recruitment strategies. Flexibility in approach and reducing the burden of enrollment procedures for participants aided enrollment. It is important to continue identifying effective recruitment strategies in studies involving patients with SCD and their providers and the impact and navigation of recruitment challenges. TRIAL REGISTRATION ClinicalTrials.Gov NCT03380351; https://clinicaltrials.gov/study/NCT03380351. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/16319.
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Affiliation(s)
- Chinonyelum Nwosu
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Hamda Khan
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Judith M Nocek
- University of Illinois at Chicago, Chicago, IL, United States
| | | | - Taniya Varughese
- Washington University School of Medicine, St Louis, MO, United States
| | - Sarah Bourne
- Medical University of South Carolina, Charleston, SC, United States
| | - Cindy Clesca
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sara R Jacobs
- RTI International, Research Triangle Park, NC, United States
| | - Ana Baumann
- Washington University School of Medicine, St Louis, MO, United States
| | - Lisa M Klesges
- Washington University School of Medicine, St Louis, MO, United States
| | | | - Jane S Hankins
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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Green NS, Manwani D, Aygun B, Appiah-Kubi A, Smith-Whitley K, Castillo Y, Soriano L, Jia H, Smaldone AM. Hydroxyurea Adherence for Personal Best in Sickle Cell Treatment (HABIT) efficacy trial: Community health worker support may increase hydroxyurea adherence of youth with sickle cell disease. Pediatr Blood Cancer 2024; 71:e30878. [PMID: 38321562 PMCID: PMC10919354 DOI: 10.1002/pbc.30878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/18/2023] [Accepted: 01/05/2024] [Indexed: 02/08/2024]
Abstract
Despite disease-modifying effects of hydroxyurea on sickle cell disease (SCD), poor adherence among affected youth commonly impedes treatment impact. Following our prior feasibility trial, the "Hydroxyurea Adherence for Personal Best in Sickle Cell Treatment (HABIT)" multi-site randomized controlled efficacy trial aimed to increase hydroxyurea adherence for youth with SCD ages 10-18 years. Impaired adherence was identified primarily through flagging hydroxyurea-induced fetal hemoglobin (HbF) levels compared to prior highest treatment-related HbF. Eligible youth were enrolled as dyads with their primary caregivers for the 1-year trial. This novel semi-structured supportive, multidimensional dyad intervention led by community health workers (CHW), was augmented by daily tailored text message reminders, compared to standard care during a 6-month intervention phase, followed by a 6-month sustainability phase. Primary outcomes from the intervention phase were improved Month 6 HbF levels compared to enrollment and proportion of days covered (PDC) for hydroxyurea versus pre-trial year. The secondary outcome was sustainability of changes up to Month 12. The 2020-2021 peak coronavirus disease 2019 (COVID-19) pandemic disrupted enrollment and clinic-based procedures; CHW in-person visits shifted to virtual scheduled interactions. We enrolled 50 dyads, missing target enrollment. Compared to enrollment levels, both HbF level and PDC significantly - but not sustainably - improved within the intervention group (p = .03 and .01, respectively) with parallel increased mean corpuscular volume (MCV) (p = .05), but not within controls. No significant between-group differences were found at Months 6 or 12. These findings suggest that our community-based, multimodal support for youth-caregiver dyads had temporarily improved hydroxyurea usage. Durability of impact should be tested in a trial with longer duration of CHW-led and mobile health support.
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Affiliation(s)
- Nancy S. Green
- Department of Pediatrics, Division of Hematology, Oncology and Stem Cell Transplantation, Columbia University Irving Medical Center, NY
| | - Deepa Manwani
- Department of Pediatrics, Division of Hematology, Oncology and Cellular Therapy, Albert Einstein College of Medicine, NY
| | - Banu Aygun
- Department of Pediatrics, Division of Hematology, Oncology and Cellular Therapy, Cohen Children’s Medical Center, NY
| | - Abena Appiah-Kubi
- Department of Pediatrics, Division of Hematology, Oncology and Cellular Therapy, Cohen Children’s Medical Center, NY
| | - Kim Smith-Whitley
- Division of Hematology, Children’s Hospital of Philadelphia, PA
- Pfizer, Inc., NY
| | - Yina Castillo
- Department of Pediatrics, Division of Hematology, Oncology and Stem Cell Transplantation, Columbia University Irving Medical Center, NY
| | - Lucy Soriano
- Department of Pediatrics, Division of Hematology, Oncology and Stem Cell Transplantation, Columbia University Irving Medical Center, NY
| | - Haomiao Jia
- School of Nursing, Columbia University Irving Medical Center, NY
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Hankins JS, Brambilla D, Potter MB, Kutlar A, Gibson R, King AA, Baumann AA, Melvin C, Gordeuk VR, Hsu LL, Nwosu C, Porter JS, Alberts NM, Badawy SM, Simon J, Glassberg JA, Lottenberg R, DiMartino L, Jacobs S, Fernandez ME, Bosworth HB, Klesges LM, Shah N. A multilevel mHealth intervention boosts adherence to hydroxyurea in individuals with sickle cell disease. Blood Adv 2023; 7:7190-7201. [PMID: 37738155 PMCID: PMC10698253 DOI: 10.1182/bloodadvances.2023010670] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/24/2023] Open
Abstract
Hydroxyurea reduces sickle cell disease (SCD) complications, but medication adherence is low. We tested 2 mobile health (mHealth) interventions targeting determinants of low adherence among patients (InCharge Health) and low prescribing among providers (HU Toolbox) in a multi-center, non-randomized trial of individuals with SCD ages 15-45. We compared the percentage of days covered (PDC), labs, healthcare utilization, and self-reported pain over 24 weeks of intervention and 12 weeks post-study with a 24-week preintervention interval. We enrolled 293 patients (51% male; median age 27.5 years, 86.8% HbSS/HbSβ0-thalassemia). The mean change in PDC among 235 evaluable subjects increased (39.7% to 56.0%; P < 0.001) and sustained (39.7% to 51.4%, P < 0.001). Mean HbF increased (10.95% to 12.78%; P = 0.03). Self-reported pain frequency reduced (3.54 to 3.35 events/year; P = 0.041). InCharge Health was used ≥1 day by 199 of 235 participants (84.7% implementation; median usage: 17% study days; IQR: 4.8-45.8%). For individuals with ≥1 baseline admission for pain, admissions per 24 weeks declined from baseline through 24 weeks (1.97 to 1.48 events/patient, P = 0.0045) and weeks 25-36 (1.25 events/patient, P = 0.0015). PDC increased with app use (P < 0.001), with the greatest effect in those with private insurance (P = 0.0078), older subjects (P = 0.033), and those with lower pain interference (P = 0.0012). Of the 89 providers (49 hematologists, 36 advanced care providers, 4 unreported), only 11.2% used HU Toolbox ≥1/month on average. This use did not affect change in PDC. Tailoring mHealth solutions to address barriers to hydroxyurea adherence can potentially improve adherence and provide clinical benefits. A definitive randomized study is warranted. This trial was registered at www.clinicaltrials.gov as #NCT04080167.
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Affiliation(s)
- Jane S Hankins
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Michael B Potter
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, CA
| | - Abdullah Kutlar
- Center for Blood Disorders, Medical College of Georgia, Augusta University, Augusta, GA
| | - Robert Gibson
- Center for Blood Disorders, Medical College of Georgia, Augusta University, Augusta, GA
| | - Allison A King
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery, Washington University, St. Louis, MO
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University, St. Louis, MO
| | - Cathy Melvin
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Victor R Gordeuk
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL
| | - Lewis L Hsu
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL
| | - Chinonyelum Nwosu
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jerlym S Porter
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Nicole M Alberts
- Department of Psychology, Concordia University, Montreal, QC, Canada
| | - Sherif M Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jena Simon
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey A Glassberg
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Sara Jacobs
- RTI International, Research Triangle Park, NC
| | - Maria E Fernandez
- Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Hayden B Bosworth
- Department of Population Health Studies, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation Durham Veterans Affairs Medical Center, Durham, NC
| | - Lisa M Klesges
- Division of Public Health Sciences, Department of Surgery, Washington University, St. Louis, MO
| | - Nirmish Shah
- Department of Pediatric Hematology and Oncology, Duke University, Durham, NC
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Rai P, Okhomina VI, Kang G, Martinez HR, Hankins JS, Joshi V. Longitudinal effect of disease-modifying therapy on left ventricular diastolic function in children with sickle cell anemia. Am J Hematol 2023; 98:838-847. [PMID: 36890729 DOI: 10.1002/ajh.26911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/30/2023] [Accepted: 03/02/2023] [Indexed: 03/10/2023]
Abstract
Cardiac abnormalities seen in sickle cell anemia (SCA) include diastolic dysfunction, which has been shown to be associated with high morbidity and early mortality. The effect of disease-modifying therapies (DMT) on diastolic dysfunction is poorly understood. We prospectively evaluated the effects of hydroxyurea and monthly erythrocyte transfusions on diastolic function parameters over 2 years. A total of 204 subjects with HbSS or HbSβ0-thalassemia (mean age 11 ± 3.7 years), unselected for disease severity, had diastolic function assessed with surveillance echocardiograms twice, 2 years apart. During this 2-year observation period, 112 participants received DMTs (hydroxyurea, n = 72, monthly erythrocyte transfusions, n = 40), 34 initiated hydroxyurea, and 58 did not receive any DMT. The entire cohort showed an increase in left atrial volume index (LAVi) of 3.40 ± 10.86 mL/m2, p = .001 over 2 years. This increase in LAVi was independently associated with anemia, high baseline E/e' or LV dilation. Individuals not exposed to DMT were younger (mean age 8.8 ± 2.9 years), but at baseline their prevalence of abnormal diastolic parameters was similar to that of the DMT-exposed participants who were older (mean age 12 ± 3.8 years). Participants on DMTs saw no improvement in diastolic function over the study period. In fact, participants on hydroxyurea saw a possible worsening in diastolic parameters (14% increase in LAVi and ~5% decrease in septal e') but also a ~9% decrease in fetal hemoglobin (HbF) levels. Further studies are needed to evaluate if exposure to DMT for a longer duration or achieving higher HbF might be beneficial in alleviating diastolic dysfunction.
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Affiliation(s)
- Parul Rai
- Departments of Hematology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Victoria I Okhomina
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Guolian Kang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Hugo R Martinez
- Division of Pediatric Cardiology, University of Tennessee College of Medicine, Memphis, Tennessee, USA.,Cardiology consultants, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jane S Hankins
- Departments of Hematology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Vijaya Joshi
- Division of Pediatric Cardiology, University of Tennessee College of Medicine, Memphis, Tennessee, USA.,Cardiology consultants, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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Hankins JS, Potter MB, Fernandez ME, Melvin C, DiMartino L, Jacobs SR, Bosworth HB, King AA, Simon J, Glassberg JA, Kutlar A, Gordeuk VR, Shah N, Baumann AA, Klesges LM. Evaluating the implementation of a multi-level mHealth study to improve hydroxyurea utilization in sickle cell disease. FRONTIERS IN HEALTH SERVICES 2023; 2:1024541. [PMID: 36925803 PMCID: PMC10012741 DOI: 10.3389/frhs.2022.1024541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/09/2022] [Indexed: 01/22/2023]
Abstract
Background Sickle Cell Disease (SCD) is a progressive genetic disease that causes organ damage and reduces longevity. Hydroxyurea is an underutilized evidence-based medication that reduces complications and improves survival in SCD. In a multi-site clinical trial, part of the NIH-funded Sickle Cell Disease Implementation Consortium (SCDIC), we evaluate the implementation of a multi-level and multi-component mobile health (mHealth) patient and provider intervention to target the determinants and context of low hydroxyurea use. Given the complexity of the intervention and contextual variability in its implementation, we combined different behavioral and implementation theories, models, and frameworks to facilitate the evaluation of the intervention implementation. In this report, we describe engagement with stakeholders, planning of the implementation process, and final analytical plan to evaluate the implementation outcomes. Methods During 19 meetings, a 16-member multidisciplinary SCDIC implementation team created, conceived, and implemented a project that utilized Intervention Mapping to guide designing an intervention and its evaluation plan. The process included five steps: (1) needs assessment of low hydroxyurea utilization, (2) conceptual framework development, (3) intervention design process, (4) selection of models and frameworks, and (5) designing evaluation of the intervention implementation. Results Behavioral theories guided the needs assessment and the design of the multi-level mHealth intervention. In designing the evaluation approach, we combined two implementation frameworks to best account for the contextual complexity at the organizational, provider, and patient levels: (1) the Consolidated Framework for Implementation Research (CFIR) that details barriers and facilitators to implementing the mHealth intervention at multiple levels (users, organization, intervention characteristics, broader community), and (2) the Technology Acceptance Model (TAM), a conceptual model specific for explaining the intent to use new information technology (including mHealth). The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework was used to measure the outcomes. Discussion Our research project can serve as a case study of a potential approach to combining different models/frameworks to help organize and plan the evaluation of interventions to increase medication adherence. The description of our process may serve as a blueprint for future studies developing and testing new strategies to foster evidence-based treatments for individuals living with SCD.
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Affiliation(s)
- J. S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - M. B Potter
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, CA, United States
- Clinical, Family, and Community Medicine, University of California San Francisco, CA, United States
| | - M. E Fernandez
- Health Promotion and Behavioral Sciences, University of Texas Health Science Center, School of Public Health at Houston, Houston, TX, United States
| | - C Melvin
- The Medical University of South Carolina, Charleston, SC, United States
| | - L DiMartino
- RTI International, Research triangle park, NC, United States
| | - S. R Jacobs
- RTI International, Research triangle park, NC, United States
| | - H. B Bosworth
- Department of Population Health Studies, Duke University, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - A. A King
- Department of Pediatrics, Washington University, Saint louis, MO, United States
| | - J Simon
- Department of Emergency Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, United States
| | - J. A Glassberg
- Department of Emergency Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, United States
| | - A Kutlar
- Augusta University, Augusta, GA, United States
| | - V. R Gordeuk
- Department of Medicine, the University of Illinois at Chicago, Chicago, IL, United States
| | - N Shah
- Department of Pediatric Hematology and Oncology, Duke University, Durham, NC, United States
| | - A. A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint louis, MO, United States
| | - L. M Klesges
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint louis, MO, United States
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